Exit Interview

Over and over again, in the months leading up to this transition, I break this news to my primary-care patients. I have developed many meaningful relationships with patients over my past three years of training as a family-medicine resident in a large, urban health center in Manhattan. But now it is time to leave and move on.

The fluorescent lights in an overly air-conditioned white clinic room illuminate face after face, all with the same look, staring back at me. Her face drops. His shoulders brace. His eyes shift. Her chronic low back pain tightens its grip. Her once improving mood slips back down. The eight-month-old bouncing and smiling on my lap quickly lunges back to Mom. She senses that her mother is hurting.

They say, "That is not what I was hoping to hear."

Or "This always happens to me!"

Or "But we just...." It trails off, and I fill in the blanks: We just connected. I just started to feel better. I finally opened up to someone about how horrible I've been feeling. We just starting working on my symptoms.

…But I trusted you.

This is an old, deep wound that I'm scratching open: loss.

For me, it's an ever-healing and tender wound--one that has been ripped open again and again by a series of losses throughout my life. I still live with the repercussions of the tragic, violent death of my father when I was little, the loss of my angelic mother-in-law to breast cancer, of a loving grandfather to a stroke, of a young and fiery uncle to a terrible car accident and of a dancing, smiling cousin to brain cancer.

There are other losses, too, that are more expected and less disastrous, like moving away, or becoming good friends with someone and then simply growing apart. Even what we call "good" life changes, like having kids or getting married, have sent people I love further from me, leaving me with an emptiness to mourn.

The especially difficult losses make me want never to open myself up again. Never to trust again. To harden and stiffen so that I will never feel that pain again.

But if I had mended those wounds so tightly that they could never reopen, then I would have missed out on so many other relationships and experiences throughout my life. Holding what is dear to us with an open hand feels vulnerable and hard. But it also leaves space for new and beautiful things to happen. This is the stuff of life: a series of losses and new beginnings.

Selfishly, I find it daunting to think of leaving these familiar faces and having to learn a brand-new set of medically complex, quirky, pain-ridden, suffering patients from scratch. Seeing the same patients over time has added meaning to my life and work as I've experienced the growth of our therapeutic relationship. Watching the babies I've delivered grow up, seeing families grow bigger, being there with them through good times and bad: All of these have deepened and enriched our relationship, adding comfort and familiarity to a job that easily overwhelms.

Having to leave my patients makes me mad. I feel like a pawn in a system of medical education that leads to fragmented care for the most vulnerable patients, perpetuating health disparities and poor health outcomes. If having continuity of care with one provider is important to patients who are wealthy and privately insured, they can easily obtain it. My patients cannot. They come to our clinic because they have very few other options for care. In dark moments, it's easy to feel that I am abandoning people who trust me--and who have taught me more than I could ever have imagined learning.

Those are big issues that I don't have answers to. But the existence of loss is a simpler reality. I can never protect myself and my patients from loss. Never. No matter how long I stay in the same clinic or town, no matter how tightly I cling to my loved ones. Loss will always return to us--an old, familiar friend, usually ugly but sometimes bittersweet.

Some losses can be sweet, because the pain makes room for new growth. For new relationships and new trust. Different than before. Not perfect, of course, but none of it ever was. The threat of losing it again, though, will always linger.

To my beloved patients, I say: Thank you for trusting me. I hope that I have served that trust well. Thank you for the very many lessons of medicine and caregiving and life that you have taught me. I wish you a new and healing relationship with the next resident who will have the privilege of taking care of you; I'm picking them out just for you. And I wish you many, many wonderful medical providers to come.

Meanwhile, I must keep informing all of you, in visit after visit, that I'm graduating and leaving the clinic.

Smiling weakly, my patients tell me that they're excited for me. They ask where I'm going, what my next steps will be.

When I tell them, nearly everyone says the same thing:

"Oh, California sounds so nice--but it is so far away."

About the author:

Tamra Travers is graduating from the Mount Sinai Downtown Residency in Urban Family Medicine at the Institute for Family Health, in Manhattan. She is moving to Ventura, CA, to begin a fellowship in faculty development at Ventura County Medical Center. Her work has appeared in HEAL, the arts and literary journal of the Florida State University College of Medicine,and can be found on her blog whitecoatwonder.tumblr.com. "I have been writing creatively since I was a child and have always enjoyed the playful expression that writing offers. After entering medicine, I realized that writing would always be an essential part of processing and exploring my interactions with life, death, relationships and healing. I felt the need to write this piece when I started breaking the news to my closest patients about my coming departure. I felt overwhelmed by the weight of the emotion I was tapping into, both for my patients and for myself."

You write about wealthy privately insured patient's having continuity of care of one provider, but those patients not. Providers move on from private practices too, move geographically or otherwise leave their patients. Happened to me a few time. I don't get that point in your otherwise great article.

This story reminds me so much of the Harvard-trained physician who was hired for our local health clinic. For the brief time she was there, I felt I was hitting the medical jackpot. But of course she didn't last long because our community is a cultural wasteland, the clinic was micro-managed by an evil administrator who truly believed that poor people deserve less medical care, and the physicians around her didn't rise to her level of conscientiousness. I would have appreciated a good-bye, but didn't get one. I would have wished her well. Good for you for facing your patients and telling them your plans.